1 OF 5 - Birth Control

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What do you want to get out of today's visit?






Tell us a little more about you

What was your last blood pressure reading? You can find this information from a recent medical visit or by taking your blood pressure at a local pharmacy or grocery store. If you're not sure, you can leave this blank.

Do any of the following situations apply to you? If so, select all that apply.

*Hormonal birth control may not be appropriate for patients in certain situations or who have certain medical issues.

Do any of these risk factors apply to you? If so, select all that apply.

*It's not always appropriate to take combination (estrogen based) hormonal birth control, as there are increased risks of major side effects, including blood clots or stroke.

Do you have high blood pressure, high cholesterol, diabetes, vascular disease, and/or heart problems (including heart attack and heart valve problems) which make it unsafe to take combination birth control?

Have you been diagnosed with migraine headaches?

*Certain migraine headaches can increase your risk of stroke and death with hormonal birth control.

Over the past 2 weeks, how often have you had symptoms of depression (feeling down or having little interest in doing things) or anxiety (feeling nervous or worrying too much)?





Let's find the right treatment for you

Have you had a pap smear test in the past three years?




Is there anything else related to treatment that you'd like to ask or discuss with your medical provider?

Would you like to share anything else with your provider through an upload?

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